Health Care Commission
Long Term Care
Presented on April 1st, 2011 by
Duane Mayes, Senior & Disabilities Services DirectorMillie Duncan, Wildflower Court AdministratorDave Cote, Pioneer Homes DirectorDenise Daniello, AK Commission on Aging Executive Director Kay Branch, AK Native Tribal Health Consortium Program CoordinatorNancy Burke, AK Mental Health Trust Program OfficerSandra Heffern, Community Care Coalition Chair
AGENDA
I. IntroductionII. Definition of Long Term Care – Who‟s Being ServedIII. History of Long Term Care – How Did We Get HereIV. What Services are Provided and By Whom
i. Skilled Nursing Facilities
ii. Pioneer Homes
iii. Home and Community Based Services
iv. Tribal Health
V. What‟s Missing In The Systemi. Senior Survey and Forums
ii. Long Term Care Housing Needs
iii. Skilled Nursing Facilities, Pioneer Homes, & Home and Community Based Services
VI. Future ActivitiesVII. Questions
DEFINITION OF LONG TERM CARE (LTC)
Meets both medical & non-medical needs Provides custodial & skilled care Requires the expertise of skilled practitioners Can be provided at:
Home
Community
Assisted Living
Nursing Home
Provides care for:People with disabilities of any age
People with traumatic brain injury
People with persistent and severe behavioral health
Seniors
CONTINUUM OF CARE
HISTORY OF LONG TERM CARE: PROGRESS STEPS
1. Provision of in-home services by home care agencies:a. Medically related home health services
b. Personal care assistance
2. 1994, Home and Community Based Care Waivers had been added to the state Medicaid programs.
3. 1990, Harborview was closed.
4. Public policy shifted to provide supports for gainful employment by persons with physical disabilities
HISTORY OF LONG TERM CARE: IMPACT
1. Get ready for work each day and maintain themselves in their own homes became a reality for hundreds of adults with physical disabilities.
2. Alaska has the second fewest nursing home beds per 1,000 people 65 years and over among all 50 states.
3. Several thousand seniors and other disabled Alaskans have chosen the CHOICE Medicaid home care waiver services, including PCA, over nursing homes.
Before the Great Depression, most of the institutionalized elderly were confined in almshouses along with the “retarded, the insane and immoral”.
SKILLED NURSING FACILITIES: HISTORY OF
NURSING HOMES
SKILLED NURSING FACILITIES: HISTORY OF
NURSING HOMES
The Social Security Act was signed by President Roosevelt on August 14, 1935. The Act included Old Age Assistance to retired workers. To discourage almshouse living, however, people living in public institutions were not eligible for the payments. That paved the way for the opening of a variety of private old-age homes, so that people could live in a care facility and still collect the Old Age Assistance payments.
EVOLUTION OF NURSING HOMES
Changes in Health Care Needs
Changes in the Hospital Reimbursement System
Development of Home Health Care & Assisted Living Homes
Nursing facilities are providing levels of care and service that were previously only given in an acute
care setting
WHY?
CHANGES IN HEALTH CARE NEEDS
In 1900, the major health problems stemmed from acute infectious diseases such as influenza and pneumonia.
United States Mortality Rates 1900-1987
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Measles Typhoid Scarlet Fever Whooping Cough Diphtheria Influenza and Pneumonia
People usually recovered or died rapidly from those diseases.
CHANGES IN HEALTH CARE NEEDS
CHANGES IN HEALTH CARE NEEDS
By mid-century, three chronic conditions alone –heart disease, cancer, and stroke – accounted for more than 50 percent of deaths.
Today, these chronic illnesses along with chronic lower respiratory diseases are the four predominant cause of death.
CHANGES IN THE HOSPITAL REIMBURSEMENT
In the mid-1980s, Medicare introduced a new payment system for hospitals based on diagnosis-related groups.
In essence, a hospital is paid a set rate according to the patient‟s particular diagnosis.
If the hospital can provide all the care necessary within that rate, it can make a profit. If the care costs more, it loses money.
The incentive for the hospital, therefore, is to discharge patients as quickly as possible –usually to a nursing home.
CHANGES IN HEALTH CARE NEEDS DEVELOPMENT OF
HOME HEALTH CARE & ASSISTED LIVING HOMES
The growth in these areas has been facilitated by the development of in-home medical technologies.
Cases that were once cared for in nursing homes are now no longer appropriate for the level of care provided in the nursing home.
THE ACUITY OF THE RESIDENTS INCREASES EACH YEAR
A study by the Kaiser Commission for the years 1999 to 2004 show disease prevalence was higher, and multiple conditions were more common, among nursing home residents in 2004, compared to 1999, indicating an increasingly sicker population
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45%
1999 2004 1999 2004 1999 2004
Persons recently admitted (resident <30 days)
Long-stay residents (90 days or longer)
Permanent residents (1 year or longer)
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DIAGNOSES OF NURSING HOME RESIDENTS
COPD Stroke Diabetes
69% had one or more of 5 physical diagnoses (COPD, stroke, diabetes, heart disease, hip fracture) in 2004, compared to 62% in 1999.
THE ACUITY OF THE RESIDENTS INCREASES EACH
YEAR
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1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
PERCENTAGE OF RESIDENTS WITH 9 OR MORE DIAGNOSIS
WILDFLOWER COURTWildflower Court has
experienced this change. The number of residents admitting to Wildflower Court with nine or more diagnosis has increased from an average of 20.2% in the 1990‟s to the past six year average of 64.8%.
MENTAL HEALTH ISSUES
The nursing home has come to play a bigger and bigger role in the care of individuals with mental health problems.
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1999 2004 1999 2004 1999 2004
Persons recently admitted
(resident <30 days)
Long-stay residents (90 days or
longer)
Permanent residents (1 year or
longer)
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sPERCENTAGE OF RESIDENTS WITH MENTAL HEALTH
DIAGNOSIS
Dementia Depression
Schizophrenia Affective and other serious disorders
One or more mental health diagnosis
MENTAL HEALTH ISSUES
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MENTAL HEALTH DIAGNOSISWILDFLOWER COURT
Dementia Depression
Schizophrenia Affective and other serious disorders
One or more mental health diagnosis
A study by the Kaiser Commission for the years 1999 to 2004 showed nationally the proportion with one or more mental or cognitive diagnoses (dementia, depression, schizophrenia, affective and other serious disorders) increased (34% compared to 27% in 1999)
MORE RESIDENTS ARE DISCHARGED TO HOME
The trend over the past 6 years is more residents are admitting for short term care and are being discharged to home.
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DISCHARGES FROM WILDFLOWER COURT
Home Expired Other LTC
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2005 2006 2007 2008 2009 2010
REASONS FOR ADMISSION FOR RESIDENTS DISCHARGED HOME
Decubitus ulcer Rehab following acute illness Rehab following cancer treatment
Rehab following fracture Rehab following stroke Rehab following surgery
The reasons for admission for the residents who discharged to home are becoming more varied requiring more diverse skills of the staff.
STAFFING CHANGES
The increased complexity of the residents has mandated a growth in the number of aides per resident day, the number of licensed practical nurses per day and in the number of RNs per resident day
PIONEER HOMES
There are six Alaska Pioneer Homes which
are licensed assisted living homes for Alaska residents 65 and older.
PIONEER HOMES: SERVICE TYPES
Level I:
Housing
Meals
Emergency assistance
Opportunities for recreation
Does not include staff assistance with activities of daily living, medication administration, or health-related services, although the Alaska Pioneer Home Pharmacy may supply prescribed medications.
PIONEER HOMES: SERVICE TYPES
Level II:
Housing
Meals
Emergency Assistance
Does include staff assistance with activities of daily living, medications administration, recreation, and health-related services.
During the night shift, the resident is independent in performing activities of daily living and capable of self-supervision.
PIONEER HOMES: SERVICE TYPES
Level III:HousingMealsEmergency assistanceDoes include staff assistance
with activities of daily living, medications administration, recreation, and health-related servicesHands-on assistance, with the staff
member performing the majority of the effortMaybe a 24-hour assistance service
PIONEER HOMES: OCCUPANCY
37%
38%
25%
June 30, 1995 Occupancy
Level I
Level II
Level III
12%
31%
57%
June 30, 2010 Occupancy
Level I
Level II
Level III
PIONEER HOMES: WAIT LIST
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1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Fiscal Year End
Total Applicants on the Pioneer Home Active Wait List
The Alaska Legislature established in regulation (7 AAC 74.060) a waitlist methodology to fairly manage requests to enter a Pioneer Home.
HOME AND COMMUNITY BASED SERVICES
Information and referral
Congregate and home delivered meals
Transportation
Homemaker and chore
Home modifications
Care coordination/case management
Respite care
Adult day centers
Program for All-inclusive Care for the Elderly (PACE)
Personal care services
HOME AND COMMUNITY BASED SERVICES
Residential Habilitation:Group homesSupported living or in-home supportsFamily Habilitation
Day HabilitationSupported Employment/Vocational TrainingIntensive Active Treatment/Nursing OversightAssisted living Home health Palliative care/Hospice Peer SupportCrisis InterventionPsychosocial Rehabilitation
ALASKA NATIVE TRIBAL HEALTH CONSORTIUM:
ROLE IN LONG TERM CARE
1. Jointly manage Alaska Native Medical Center
2. Statewide tribal health coordination and collaboration:
a. Alaska Tribal Health System Long Term Care Committee
b. Alaska Native Elder Health Advisory Committee
c. Medical Services Networking Committee/Clinical Directors Committee
3. Focus on home and community based and residentially based care
ALASKA NATIVE TRIBAL HEALTH CONSORTIUM:
BACKGROUND
Alaska Native population living longer: Current estimates are 8,000 over 65 today Number will more than double in 20 years
Majority live in Alaska‟s rural and very remote communities:Migration into more urban communities Access to health facilities Family/economic factors
Significant need for long term care among younger, disabled Alaska Native people
Indian Health Service has not historically funded long term care
ALASKA NATIVE TRIBAL HEALTH CONSORTIUM:
BENEFITS TO THE STATE
100% FMAP for Medicaid LTC services provided to Alaska Native people by tribal health organizations
Annual savings to the State General Fund
ALASKA NATIVE TRIBAL HEALTH CONSORTIUM:
CHALLENGES AND GAPS IN LTC
Home and community based services not widely available in rural areas:ATHS LTC committee working with DHSS to increase availability
and access
Few options for residential LTC in rural Alaska:Current facilities in Nome, Kotzebue, Dillingham and Tanana
Facilities funded for construction in Bethel and Kotzebue
Facility for Anchorage partially funded
Alaska Commission On Aging: Senior Survey
Elder Senior Community Forums
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1980 1990 2000 2005 2009 2010 2015 2020 2025 2030
Alaskans Age 60+(U.S. Census; AK DOL Estimates; AK DOL Projections)
Growth of Alaska’s Senior Population 1980-2030
WHAT’S MISSING IN THE SYSTEM: SENIOR SURVEY AND FORUMS
Senior Survey: 4-page survey for Alaskans age 50 and older; distributed through the Senior Voice, senior meal programs, and other methods; received 3,222 responses from Alaskans 50 years and older with 2,836 coming from seniors 60 years+.
Provider Survey: On-line questionnaire about current and projected senior needs and service usage; received 50 responses.
Six Elder-Senior Community Forums: Anchorage, Fairbanks, Juneau, Kotzebue, Bethel, and the Alaska Native Tribal Health Consortium Elders Committee
NEEDS ASSESSMENT & METHODOLOGY FOR DEVELOPMENT
OF ALASKA STATE PLAN FOR SENIOR SERVICES, FY 2012-
2015
WHAT’S MISSING IN THE SYSTEM: SENIOR SURVEY AND FORUMS
Senior SurveyHealth Care Financial SecurityHousingUse of Senior Services
Provider Survey Serving more seniors with limited fundingWorkforce Financial security, health care & senior
hungerAdditional long-term supports for seniors
FINDINGS ON SERVICE GAPS IN THE CONTINUUM OF CARE FOR
OLDER ALASKANS
WHAT’S MISSING IN THE SYSTEM: SENIOR SURVEY AND FORUMS
Elder-Senior Community ForumsAccess to primary careExpansion of long-term care support services; limited Medicaid
services in rural areas Senior housing, senior homelessness, seniors with complex
behavioral health needsTransportation Services for people with ADRD, cognitive disabilities, brain
injury, & behavioral health needsCaregiver support & trainingElder Safety Information & ReferralHospice & End of Life Care
FINDINGS ON SERVICE GAPS IN THE CONTINUUM OF CARE FOR
OLDER ALASKANS
Alaska Mental HealthTrust Housing Focus Area Goals
Supported housing stock – the backbone of long term care services
• Technical assistance and assessment:
Improving capacity to maintain the social service component needed for successful housing
programs
Direct support for social service agencies struggling to maintain housing programs
• Piloting programs to more effectively serve Trust beneficiaries• Special Needs Housing grant program adaptations to incorporate resources needed for projects
to „pencil‟
• Work with the Department of Health and Social Services to coordinate services, including multi-
agency partnerships and shared treatment plans.
Alaska Mental HealthTrust Housing Focus Area Goals
Why focus on housing?• Housing in the community with supportive services is cost
effective when compared to skilled nursing and residential assisted living
• State responsibility to maintain home and community based options for people with disabilities and mental illness (Olmstead decision under the Americans with Disabilities Act)
Supported housing is key to stability for residents:Programs in Seattle, Anchorage and Sitka have demonstrated health
outcomes for residents▫ 30% reduction in drinking for people with abuse history in supported
housing▫ Increased access to health services and decreased use of emergency
level services▫ Stability in housing led to engagement with community and
increased mental and physical health outcomes
FUTURE ACTIVITIES
• Review past studies & LTC Plans to identify Alaska LTC recommendations.
• Provide LTC recommendations in May, 2012
• Questions??
Thank you for your participation!
